Early Childhood Mental Health in Colorado:

Transcription

1 January 15, 2013 Early Childhood Mental Health in Colorado: An Environmental Scan of Challenges, Progress and Recommendations for the Social and Emotional Health of Colorado s Young Children Sarah Davidon Hoover, M.Ed. and Lorraine F. Kubicek, Ph.D. This report has been prepared for Caring for Colorado Foundation and Rose Community Foundation by JFK Partners at the University of Colorado School of Medicine Anschutz Medical Campus

2 Contents Executive Summary... 2 Acknowledgements... 4 Introduction... 5 Definition of Early Childhood Mental Health... 6 Overview of Early Childhood Mental Health... 6 A Snapshot of Children s Mental Health... 7 The Importance of Early Prevention and Intervention... 7 Philanthropic Investments... 8 Promotion, Prevention and Intervention... 8 Expected Results from Philanthropic Investment... 9 Initiatives, Organizations, Programs and Services... 9 Early Childhood Mental Health Goal Areas: Where We Are and Where We Need to Go Public Engagement Professional/Workforce Development Funding Program Availability Integrated System of Care Child and Family Wellbeing School Readiness Appendix A. Methodology Appendix B. Colorado s Early Childhood Mental Health Initiatives, Programs and Resources. 30 Appendix C. Early Childhood Framework Colorado Appendix D. Philanthropic investment and partnerships in other states An environmental scan to inform philanthropic impact, public policies and program development 1

3 Executive Summary Early Childhood Mental Health in Colorado Early childhood mental health is the capacity of children from birth to five years to form close and secure adult and peer relationships, experience, manage, and express a full range of emotions, and explore the environment and learn all in the context of family, community, and culture. This developing capacity is inextricably linked to children s cognitive, communicative, and physical development and significantly impacts the wellbeing of every family with young children. To support the healthy development of our young children, it is essential to create a comprehensive system that supports a continuum of mental health services and has the capacity to deliver those services statewide. Despite a growing awareness of the importance of mental health to future wellness and recent progress to address gaps in its current system, Colorado s early childhood mental health system remains inadequate to promote the healthy development of its young children, prevent problems for those at risk, and treat the symptoms of children with diagnosed mental health disturbances. Rose Community Foundation and Caring for Colorado Foundation have a long history of supporting early childhood mental health in Colorado and together saw an opportunity to collaborate and explore a shared strategy to move the field forward. To that end, the Foundations contracted with JFK Partners, University of Colorado School of Medicine, to identify opportunities and develop recommendations for philanthropy to address the unmet mental health needs of Colorado s young children and their families at the levels of promotion, prevention, and intervention through effective programs and policy solutions. The resulting environmental scan included comprehensive data from: (1) an extensive review of relevant literature and documents, (2) an analysis of key informant interviews and focus groups, and (3) a summary of early childhood mental health service data. Data were organized to provide an understanding of the current status of, and to support recommendations to build upon, each of the five goal areas identified in Colorado s Early Childhood Mental Health Strategic Plan in Two additional goal areas were added based on findings from the environmental scan. The seven goal areas are: Public Engagement, Professional/Workforce Development, Funding, Program Availability, Integrated System of Care, Child and Family Wellbeing, and School Readiness. Despite notable accomplishments and new opportunities related to each of the goal areas, a review of the data highlighted challenges to improving and expanding Colorado s system of early childhood mental health and led to the proposed recommendations. For example, the current workforce is insufficient, and there is a notable lack of incentives and supports for professionals to seek specialized training and remain in the field. While quality programs and services exist, availability is often unequal and limited to certain geographic areas. Despite the importance of early identification and treatment, screening for childhood social and An environmental scan to inform philanthropic impact, public policies and program development 2

4 emotional difficulties is inconsistent among providers. Moreover, current Medicaid policies are often not flexible enough to cover treatment appropriate for young children. The accompanying full report includes recommendations for funders to address these and related challenges as they work with other funders, government, social service agencies, and mental health professionals to find enduring, systemic solutions. Overarching considerations should include: Colorado s policy, system and program readiness to address early childhood mental health issues statewide and the ability to integrate early childhood mental health into existing health care coverage and networks, The current effectiveness and preparedness of state and local mental health systems to provide access to parents and caregivers, The ability to identify and take to scale best models and best practices of effective early childhood mental health care, The importance of integrating the perspectives of parents, caregivers, state agencies, childcare providers and health care professionals, The need to take account of differences among system capabilities and structures in rural and urban communities. An overview of each of the seven goal areas with their respective objectives, progress, challenges, opportunities, current direction, and recommendations is provided in the report that follows. An environmental scan to inform philanthropic impact, public policies and program development 3

5 Acknowledgements We want to express appreciation to our Colorado colleagues who generously shared their expertise and gave their time to reflect on where our state currently is with regard to early childhood mental health and where we still need to go to improve access, availability, and quality of care for all of our state s young children and families. We also wish to thank the experts outside of Colorado with whom we consulted who provided us with a national perspective on these important issues. Last, we want to acknowledge and thank Rose Community Foundation and Caring for Colorado Foundation for recognizing the importance of early childhood mental health to the overall health and wellbeing of Colorado s young children and families and for supporting efforts to identify opportunities for philanthropy. Sarah Davidon Hoover, M.Ed. Lorraine F. Kubicek, Ph.D. JFK Partners, University of Colorado School of Medicine Anschutz Medical Campus An environmental scan to inform philanthropic impact, public policies and program development 4

6 Introduction Early childhood mental health is inextricably linked to children s cognitive, communicative, and physical development and significantly impacts the wellbeing of every family with young children. Rose Community Foundation and Caring for Colorado Foundation recognize the importance of early childhood mental health and have conducted an analysis of recent progress and current conditions related to the mental health of young children and their families in Colorado. This report provides the results of an environmental scan intended to identify opportunities and support recommendations for philanthropy to address the unmet mental health needs of young children and their families in our state at the levels of promotion, prevention and intervention through effective programs and policy solutions. There are a variety of early childhood mental health programs that range from broad-based initiatives targeting the general population to highly specialized services targeting children with severe challenges. Policymakers are expected to make recommendations and changes to state-funded programs, and funders are expected to demonstrate accountable investment where they can achieve the greatest impact. Yet neither may have a comprehensive picture of the interconnected programs and policies that comprise Colorado s early childhood mental health system. Having a baseline understanding of current programs and the policies that affect how they are delivered and funded is essential when making important decisions about their future. This report establishes such a baseline using data from an environmental scan which included: (1) an extensive review of relevant literature and state-level documents, (2) an analysis of key informant interviews and focus groups, and (3) a summary of early childhood mental health service data. A detailed description of the methodology can be found in Appendix A. A baby alone does not exist. A baby can be understood only as part of a relationship. D.W. Winnicott Children are happy, healthy, and have good relationships with others. A Colorado parent defining early childhood mental health An environmental scan to inform philanthropic impact, public policies and program development 5

7 Definition of Early Childhood Mental Health Early childhood mental health is defined as the developing capacity of the child from birth to five years to form close and secure adult and peer relationships, experience, manage, and express a full range of emotions, and explore the environment and learn--all in the context of family, community, and culture. i The terms early childhood mental health and early socialemotional development are often used interchangeably. For the purpose of this report, we use the term early childhood mental health to mean healthy social-emotional development. In so doing, we recognize the importance of promoting healthy social-emotional development as well as preventing and treating mental health problems. Overview of Early Childhood Mental Health There is a growing recognition of the importance of helping young children get a good start in life by providing opportunities for healthy social-emotional development from birth. Early childhood is a critical time for the identification of emotional and behavioral issues, since left untreated, they can have long term detrimental effects on learning, social competence, and overall health and wellbeing. We know that the brain develops especially rapidly during the prenatal period through age three and provides the foundation for children's healthy development throughout life. Cognitive, language, emotional and social abilities are inextricably linked and develop together through the interaction of brain growth and experience. ii iii It is critically important for the general public to understand that contrary to popular belief, all children do not have mental health. Even in very young children, mental health problems (referred to in children as serious emotional disturbance by the federal Substance Abuse and Mental Health Services Administration) can and do exist and are the result of an interaction between genetic predispositions and life experiences. iv During infancy and toddlerhood, mental health problems might present as an inability to express or manage emotions or form secure attachments with caregivers. During the preschool period, mental health problems might present as challenging behaviors such as being persistently disruptive or consistently quiet and withdrawn in child care settings. Young children develop in the context of relationships. Findings from both research and clinical work indicate that the emotional quality of the parent-child relationship has a profound effect on the health and wellbeing of young children. Sensitive, responsive and dependable relationships are key to providing the support and encouragement all children need for positive growth and development. v Unfortunately, there are a variety of risk factors which can negatively impact the quality of these relationships and in turn, compromise An environmental scan to inform philanthropic impact, public policies and program development 6

8 children s mental health. These include environmental factors such as exposure to violence, chronic fear and stress, abuse and neglect, poverty, maternal depression, parental substance abuse, teenage parents, and foster care and biological factors such as genetic prematurity and low birth weight. These risk factors can result in childhood depression, attachment disorders, and traumatic stress disorders that require appropriate intervention to prevent them from becoming more serious over time. vi A Snapshot of Children s Mental Health Estimates of the number of children suffering from serious mental health problems vary significantly depending on the study cited. A literature review revealed national estimates ranging from 5% to 26%. vii Many more children may have difficulties in the social and emotional realm that do not reach the level of serious but interfere with the child s optimal development, ultimately affecting their ability to be ready for school and life. The Colorado Child Health Survey (2011) viii indicates that 16% of Colorado s parents report concerns about their children s emotions, concentration, behavior, or getting along with others. Of these, 64% identify these difficulties as moderate or severe, yet only 25% of these parents reported seeking counseling or treatment. Approximately 346,000 children under the age of six years live in Colorado. According to the Division of Behavioral Health, approximately 3,640 children under the age of six years, or 1%, receive services through Colorado s public mental health system. ix x Children under the age of six years with serious mental health problems have the highest unmet need for mental health services in the state (which is calculated by prevalence minus service utilization), with only a 30% penetration rate compared to a rate of 91% for children in Colorado ages six to eleven years of age. xi In early care and education settings in Colorado, 11% of care providers report that children under the age of six years in their care demonstrate ongoing and interfering behaviors such as hurting themselves or others, showing disrespect or defiance, or being irritable, mad, frustrated, or withdrawn. Ten out of every 1,000 children or 1% are being removed from their early care and education setting due to challenging behaviors, with family child care homes dismissing children from their care at a rate six times higher than that in child care centers. xii The Importance of Early Prevention and Intervention Effective interventions for children ages birth to three years are essential since this is the time when rapid cognitive, language, social, and emotional development occur. Between the ages of three and five years, development in these areas continues, building on the foundation laid during this earlier critical period. Necessary elements of healthy socialemotional development such as peer social skills, emotional control, and language continue to develop during this time and need to be supported so that young children have An environmental scan to inform philanthropic impact, public policies and program development 7

9 opportunities to engage with and learn from others. Figure 1 xiii demonstrates the range of sensitive periods in brain development that occur before children reach school age. Philanthropic Investments Promotion, Prevention and Intervention Nationally, emphasis tends to be on an early childhood mental health model of promotion (available for all children) and prevention (impacting children at risk). Programs that support intervention are typically not as high a priority for funders as are those that support early learning and health. Reasons for this may vary. Many funders may not be aware that healthy social-emotional development is essential for overall health, wellbeing and success in school and life. Some may want to have the broadest impact on the greatest number of children as possible, and so they support programs that cover the universal population of children or those at-risk with the hope of preventing children from reaching the deep end. Other funders view intervention and treatment as services covered by insurance companies or public programs for which philanthropic funding is therefore not needed. Consistent with national trends, there is limited philanthropic investment in early childhood mental health intervention in Colorado, with more focus on promotion of mental health or prevention of mental illness for children at risk. Findings from focus groups and surveys of Colorado funders conducted on behalf of the environmental scan show the following: Types of Initiatives 87% identified that they fund direct services, supports or goods 63% indicated that they fund infrastructure, systems change or professional development 25% indicated that they fund policy An environmental scan to inform philanthropic impact, public policies and program development 8

10 Level of Intervention 86% indicated that they fund programs and initiatives at the promotion level 71% fund initiatives at the prevention level 43% support treatment/intervention Expected Results from Philanthropic Investment Funders of early childhood mental health initiatives primarily rely on grantees to gauge their own success. While the desired outcomes identified by funders are valuable and appropriate for early childhood mental health initiatives, the range of desired outcomes they reported demonstrates that there is limited consistency across funders in expected measures of success for these initiatives. Their responses, which are listed below, ranged from child and family outcomes to program and system outcomes: Child and Family Desired Outcomes Fewer behavior problems and expulsions Children are emotionally and socially ready to learn, increasing their likelihood to be successful in school Increased social/emotional wellbeing for children Greater family and child resiliency Program and System Desired Outcomes Classroom environment that supports positive social-emotional development ECE workforce that can support the needs of young children Follow-up/referral from screenings Increased access to treatment/intervention Improved classroom management skills Increased number of environments providing early identification and mental health consultation Systems change that results in cross systems collaboration between early learning and early childhood mental health Initiatives, Organizations, Programs and Services Early childhood mental health services in Colorado are delivered through a variety of early childhood and mental health organizations, providers of child care, health care, and early intervention. Early childhood mental health services exist in a system that is more complex than simply the traditional mental health system. When making decisions about programs and funding, funders and policymakers should consider the complex and interconnected nature of early childhood education, health and mental health programs. A literature review, discussions with key stakeholders across Colorado and the nation, and reports on the topic of early childhood and early childhood mental health have provided An environmental scan to inform philanthropic impact, public policies and program development 9

11 information about what supports and services should be included in a comprehensive system of early childhood mental health care. This information has been documented in Colorado s Early Childhood Mental Health Strategic Plan. xiv Consensus on the categories of early childhood mental health services that need to exist to have a strong, coordinated system are shown in Figure 2. Figure 2. Early childhood mental health system of services and supports For this report, a descriptive listing of initiatives, organizations, programs and services has been developed and is included in Appendix B. In summary, Colorado s current early childhood mental health system crosses sectors and, in addition to private mental health practices and pediatric health practices, is made up of: membership organizations (10) advocacy organizations (10) programs and direct services (32) resources, information and technical assistance (19) training and professional development (15) While a number of initiatives cross over into more than one category (e.g., a program that offers a direct service might also provide technical assistance), initiatives have been categorized into a primary category. It is important to note that the quantity of initiatives and organizations within these categories does not necessarily tell us about the capability of the state to serve young children. Geographic coverage, program restrictions and program capacity all need to be factored in as one reviews this listing. For additional information about program and service capacity, use of the Colorado Social-Emotional and Mental Health Navigation Guide xv is suggested as a resource to discover more about populations served, goals of the programs, evidence base, and capacity for expansion. Colorado has been working on early childhood mental health programs and initiatives for over ten years and is home to some of the nation s leading experts in early childhood mental health. However, until recently, a statewide strategy has been lacking. The Blue Ribbon Policy Council for Early Childhood Mental Health was formed in 2004 and developed a strategic plan An environmental scan to inform philanthropic impact, public policies and program development 10

12 for fully embracing early childhood mental health across the state. The strategic planning process began when a general consensus was reached that called for better integration, definition, and coordination of Colorado s early childhood mental health systems, services and supports. Key elements that drove the formal strategic planning process were: Changes in the way professionals who work with young children view their role and potential to support children s social, emotional and behavioral health Enhanced recognition of the importance of preventing mental health problems at an early age Increased information on the status of Colorado s young children s social, emotional and behavioral health Recognition that traditional mental health services do not adequately meet the needs of young children and their families Statewide work to develop a comprehensive system for early childhood that includes mental health as an essential domain Five goal areas were identified in the Strategic Plan which now serves as a framework for gauging our state s recent progress and current conditions in early childhood mental health. This report is organized by the Strategic Plan goal areas, including: 1. Public Engagement: The people of Colorado have a common understanding of early childhood mental health and embrace and support the healthy social and emotional development of young children. 2. Professional and Workforce Development: All personnel in disciplines working with young children and their families use effective promotion, prevention and intervention strategies for mental health. 3. Funding and Finance: Financial and human investments and policies regarding children s mental health follow a framework for promotion, prevention and intervention, are embedded within Colorado s early childhood system, and demonstrate accountability. 4. Program Availability and Access: Colorado families and caregivers are able to easily obtain appropriate and affordable mental health resources and supports for their children and themselves at the promotion, prevention and intervention levels. 5. Integrated System of Care: A comprehensive, coordinated and effective system of care exists that supports early childhood mental health. Two additional goal areas emerged as this report was developed. They are included in the organization of, and recommendations in, this report as well: 1. Child and Family Wellbeing: Children enter kindergarten socially and emotionally prepared and ready to learn. 2. School Readiness: Foster increased family stability and the development of strong bonds between young children and their parents. Colorado s Early Childhood Mental Health Strategic Plan continues to be reviewed and updated quarterly by the Blue Ribbon Policy Council for Early Childhood Mental Health. The development of this report has provided a useful update to the information in the Strategic An environmental scan to inform philanthropic impact, public policies and program development 11

13 Plan, which was developed in 2008, and a helpful opportunity to focus on specific issues and priorities of interest to the philanthropic community. While the Blue Ribbon Policy Council has developed recommendations from the Strategic Plan, these may differ from the recommendations included in this report in that here the authors have prioritized recommendations for philanthropic impact. Recommendations are included in this report based on opportunities that could promote success, the level of evidence that is available regarding the potential success and impact of the recommendation, and those that are strategies that can be employed by philanthropic organizations. In 2008, the Early Childhood Colorado Framework (Appendix C) was developed to represent Colorado's vision for a system of partners and efforts that will lead to all Colorado children being valued, healthy, and thriving. It was developed as the overarching and unifying vision for a comprehensive early childhood system that encompasses the four early childhood domains of: early learning family support and parent education social emotional and mental health health This report, as well as Colorado s early childhood mental health system, have been developed in the context of the Early Childhood Colorado Framework and the resulting related work of the Colorado Early Childhood Partnership (listed in Appendix B), as well as the Colorado Early Childhood Mental Health Strategic Plan. Early Childhood Mental Health Goal Areas: Where We Are and Where We Need to Go The following sections are organized to provide an understanding of the current status and future direction in each goal area of Colorado s Early Childhood Mental Health Strategic Plan plus the two new goal areas that were added for this project. Each goal area is organized to include: Objectives Progress (related to the Strategic Plan) Challenges Opportunities Current Direction Recommendations An environmental scan to inform philanthropic impact, public policies and program development 12

14 PUBLIC ENGAGEMENT Goal The people of Colorado have a common understanding of early childhood mental health and embrace and support the healthy social and emotional development of young children. Objectives The general public has a shared understanding of: The foundational importance of early childhood mental health to overall health, wellbeing, and success in school and throughout life, How best to promote early childhood mental health, Age-appropriate behaviors for children aged birth through five years and how to recognize when behaviors warrant professional attention. Progress The Early Childhood Colorado Framework includes social, emotional and mental health as a priority outcome area. Related work on the Framework in Action includes social, emotional and mental health activities. Colorado s Early Learning and Development Guidelines, which describe what children should know and be able to do from birth to age eight years and focus on supporting children s learning and development in a variety of domains, include social-emotional development as one of the domains. The state s 31 Early Childhood Councils include early childhood mental health as a priority. The Councils are community-based partnerships that are working to build a comprehensive system that connects children, families and resources to quality services in education, health, mental health, and family support. Social-emotional development and Early childhood mental health consultation services have been recently (2010) defined in Colorado s Rules Regulating Family Child Care Homes. Licensed family child care providers are now required to take three hours of continuing education focused on children s social-emotional development. Challenges There is a lack of key public service messages that reach a wide audience and effectively and consistently communicate the foundational importance of early childhood mental health to overall health, wellbeing and success in school and throughout life. Many in the general public are not aware of age-appropriate norms and expectations for young children, particularly with regard to social, emotional, and mental health. Many in the general public do not understand that young children can suffer from mental health problems that are serious enough to warrant professional attention. The ongoing stigma associated with mental health problems discourages many from seeking professional help for themselves or their children. Immigrant and refugee families living in our state may have cultural norms and expectations for young children that are very different from our own mainstream culture. An environmental scan to inform philanthropic impact, public policies and program development 13

15 Opportunities A successful public engagement campaign must be culturally relevant and address the changing demographics in our state. The Colorado Trust has developed resources for cultural and linguistic competency in mental health which can help to support this endeavor. Current Direction Anecdotal reports suggest an increase in public awareness of the importance of early brain development and the impact of the first five years on school readiness and long term health and wellbeing. Recommendations Convene early childhood mental health partners, including funders and stakeholders from the Blue Ribbon Policy Council for Early Childhood Mental Health and the Colorado Association for Infant Mental Health (CoAIMH) to: Target one key issue with a social marketing campaign. A public perceptions survey would be used to help identify the highest priority issue. Review the effectiveness of past social marketing efforts and the relevance of existing materials (e.g., Project BLOOM, ZERO TO THREE) and decide how best to disseminate the information. PROFESSIONAL/WORKFORCE DEVELOPMENT Goal All personnel in disciplines working with young children and their families use effective promotion, prevention and intervention strategies for mental health. Objectives Colorado has adequate numbers of trained professionals at all levels in the appropriate disciplines (e.g., early intervention, early care and education, mental health, medical, child welfare) who have the specialized knowledge, skills, training, and support in early childhood mental health that they need to work effectively with and on behalf of young children and their families. Any professional who touches the life of a young child has adequate training in early childhood mental health. Recognized standards are in place to assess professional competency in early childhood mental health, and professionals are required to meet them. Progress The Colorado Association for Infant Mental Health (CoAIMH) has grown as a professional organization and is increasingly recognized as a leader in promoting early childhood mental health statewide. CoAIMH has developed a website that identifies job opportunities, trainings and resources related to early childhood mental health. CoAIMH has joined 14 other states in purchasing and adopting the nationally vetted Michigan Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting An environmental scan to inform philanthropic impact, public policies and program development 14

16 Infant Mental Health (Colorado Infant/Early Childhood Mental Health Endorsement. The Endorsement is one of the first and most comprehensive efforts in the country to identify best practice competencies at multiple professional levels and across disciplines. Eligible professionals range from those who have worked in the early childhood field for at least two years to those who have received a doctorate in their field. Social-emotional training is included in Colorado s Rules Regulating Family Child Care Homes. Colorado s Coaching consortium ( is defining an early childhood coaching system that includes early childhood mental health initiatives as partners. JFK Partners offers an annual two-day professional training in Colorado on the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: DC: 0-3R. There is collaboration with health care professionals (through the Assuring Better Child Health and Development (ABCD) initiative and other pilot projects) and child care nurse consultants (through child care early childhood mental health consultation initiatives) on training and resource development in early childhood mental health, including social-emotional screening. Colorado Early Childhood Social & Emotional Interdisciplinary Core Knowledge & Credential has been developed. It is a voluntary credential with a quality assurance, self-assessment, and professional development framework for practitioners who work with young children and families, and who serve in a capacity to impact their social and emotional health. Community college coursework for ECE has been revised to include content that addresses children s social-emotional health. Challenges Colorado lacks adequate numbers of trained professionals at all levels in the appropriate disciplines (e.g., early intervention, early care and education, mental health, medical, child welfare) who have the specialized knowledge, skills, training and support they need in early childhood mental health to meet even the current demand for services. Many colleges and universities continue to produce professionals who are trained to operate in silos rather than in an integrated system of care. There is a lack of incentives and supports for professionals to seek specialized training and remain in the field. These include: a) a lack of incentives to seek the Endorsement, e.g., no added financial compensation, no requirement making the Endorsement a necessary credential for certain professional positions (as has been done by other states that have adopted the Endorsement), b) reflective supervision is a requirement for completing the Endorsement at certain levels, but since this is a relatively new expectation and model of practice, it is not currently part of our supervisory structure, and c) lack of professional support for early childhood mental health providers which can lead to burnout and a substantial amount of turnover. Turnover affects quality of care since it not only takes time, but it may also be difficult, for children and families in treatment to develop a trusting relationship with a new provider. An environmental scan to inform philanthropic impact, public policies and program development 15

17 Opportunities The recent establishment of the Office of Early Childhood provides opportunities for programs to work more closely together, understand gaps, duplication, and efficiencies, and consolidate programming that serves the same population. Having related programs housed in the same office could be a good professional development opportunity to establish consistent expectations across providers. The P-3 Professional Development Committee is establishing workforce competencies and embedding early childhood mental health. The Colorado Commission on Higher Education reversed an earlier decision made 25 years ago thereby making it possible for Colorado colleges and universities to offer a bachelor s degree in Early Childhood Education. Their decision recognizes the need to professionalize this career, produce more effective teachers who can better help children be ready for kindergarten, and help Colorado meet new federal regulations requiring 50% of early childhood education teachers to have BA degrees in early childhood education or a related field by The adoption of the Colorado Endorsement for Culturally Sensitive, Relationship-focused Practice Promoting Infant Mental Health provides a nationally recognized standard for expertise in infant mental health at multiple professional levels across disciplines. A partnership between Weld County (through a federal LAUNCH grant) and CoAIMH has provided an opportunity to promote the Endorsement and increase the number of professionals seeking/receiving it. The recently awarded Race to the Top: Early Learning Challenge includes strategies to promote professional development in the early childhood workforce through a competency based system that supports both formal and informal education opportunities and allows an evaluation of educator effectiveness linked to Colorado s K-12 system. Current Direction CoAIMH continues to provide ongoing training opportunities as well as to inform professionals about training, mentoring, outreach and support opportunities. There is increasing recognition of the importance of the Endorsement as a standard for professional competency at multiple professional levels in early childhood mental health and of reflective practice and supervision as an essential component of best practice in early childhood mental health. CoAIMH maps their trainings and presentations to the Endorsement competencies and is currently finalizing a Reflective Supervision Registry to help professionals meet requirements for Endorsement. Adoption of the Endorsement provides an opportunity to advocate at the policy level for differential reimbursement in health care payment systems. There is a growing appreciation of the need for programs to adopt promising practices, research informed best practices, and evidence-based practices in their promotion, prevention and intervention work with children and families. An environmental scan to inform philanthropic impact, public policies and program development 16

18 Recommendations Work with Colorado colleges and universities to integrate early childhood mental health competencies (using the Endorsement as a guide) into the training of all professionals who work with young children and their families and ensure a collaboration with Colorado higher education programs offering bachelor s degrees in early childhood education. Support students in compiling their required portfolios for the Endorsement prior to graduation to position them to apply for the Endorsement as soon as their schooling is completed. Fund CoAIMH s efforts to build a sustainable infrastructure to house the Endorsement, e.g., provide funding for paid personnel to disseminate information and coordinate the application process, increase capacity for reflective supervision, and maintain a Reflective Supervision Registry as well as a registry of all endorsed professionals. Promote professional standards and sponsor a review of current payment systems for all levels of disciplines (from paraprofessional through clinician) to determine feasibility of a pay differential and/or other incentives based on demonstration of knowledge and competency through the Endorsement, including Medicaid differential reimbursement. Review the feasibility of requiring the Endorsement as a qualification for certain professional positions. Commit funding for the integration of social-emotional models and practices and for professional development and practices that foster the inclusion of children with social, emotional, behavioral and developmental concerns. FUNDING Goal Financial and human investments and policies regarding children s mental health follow a framework for promotion, prevention and intervention, are embedded within Colorado s early childhood system, and demonstrate accountability. Objectives Colorado s early childhood mental health system of care is cost effective, fiscally sound, and sustainable with funding allocated to delivering services in environments where young children and their families naturally are. Adequate funding is available to increase the implementation of evidence-based practices in lieu of less effective practices as well as support research and evaluation to assess whether programs, practices and policies are being implemented with fidelity and are having their intended effects. Private insurance providers and Medicaid adopt more flexible eligibility criteria that allow payment for services for young children who have recognized mental health difficulties but do not necessarily meet specific diagnostic criteria and for relationshipbased treatment for young children and their parents. Ensure a voice at the table to represent early childhood mental health whenever issues/policies that affect young children and their families, e.g., early care and education, mental health, primary care, health care reform, are under discussion. An environmental scan to inform philanthropic impact, public policies and program development 17

19 Progress Colorado programs have made investments to provide for currently unfunded/nonreimbursable services, such as program-focused early childhood mental health consultation. Foundations are investing in early childhood social-emotional and mental health. Rose Community Foundation is recognized as a valuable community-based funder that is willing to support initiatives others may not find attractive, e.g., intensive, higher end services for smaller numbers of clients such as the Doula project or Fussy Babies. The Community Foundation in Boulder County is providing support to nonprofits to help them become more self-sustaining through board development, organization, and technology, which has helped emerging nonprofits supporting early childhood mental health succeed. Colorado has developed learning models on which to build, including co-located primary health and behavioral health care services. There are increased public investments in early childhood mental health such as the Early Childhood Mental Health Specialists and a focus on social-emotional health in the Medical Home approach. Challenges Even when insurance covers mental health, the coverage is often inadequate to provide the appropriate level of care young children and their families need. Reimbursement is often not flexible enough to accommodate a relationship-based treatment model where the parent-child dyad or the family, rather than the individual child, is considered to be the client (billable unit). Reimbursement often requires a diagnosis even though the mental health difficulties a child/family may be experiencing do not meet specific diagnostic criteria, which may preclude preventative mental health care in early childhood. Early screening and family risk assessment, both considered important for appropriate treatment within an integrated system of care for early childhood mental health, are often not reimbursed (by private insurance or Medicaid). There is often a lack of funding for research/evaluation, even though evaluation is essential to assess whether or not programs and services are being implemented with fidelity and are having their intended effect. Lack of a consistent set of standardized measures by which to assess progress in early childhood mental health. Early childhood discussions in Colorado consistently lack a mental health voice, essentially making early childhood mental health either an afterthought or a forgotten domain, primarily because there is no consistent advocate to represent the interests of the early childhood mental health community in systems discussions. There is less philanthropic emphasis on funding policy-related activities or initiatives, although policy issues are often at the heart of barriers to long-term sustainability of programs or direct services. Opportunities Funding of the Pyramid Plus Center has enhanced its presence and provides a model of a partnership that includes public funding, Mile High United Way, the Colorado Health Foundation, and the University of Colorado. This partnership has helped to sustain the program and move early childhood mental health forward in Colorado. An environmental scan to inform philanthropic impact, public policies and program development 18

20 Although there is no funded advocate for early childhood mental health at this time, the Blue Ribbon Policy Council and CoAIMH, both volunteer membership organizations, help to promote and keep an eye on relevant issues in the state. The creation of Colorado s Office of Early Childhood within the Department of Human Services serves as an opportunity to consolidate and better administer early childhood programs in Colorado, including early childhood mental health. There is a dedicated position for early childhood mental health within the Office, but there is insufficient funding to fully support it. This position could help to address many of the issues, challenges and recommendations made in this report, and therefore is itself an opportunity to move forward. Current Direction Funding tends to focus on promotion and prevention even though there is a need to support a full continuum of services that includes treatment and intervention. Efforts have been successful, in limited ways, to financially support strategies that help providers, communities and families better understand early childhood mental health choices, programs and initiatives in Colorado. However, there is still a need for a more comprehensive and robust system for navigating early childhood mental health resources in the state. Though limited, evaluations are being conducted on a number of current programs that are being implemented, e.g., early childhood mental health consultation, Pyramid Plus, and The Incredible Years. Recommendations Collaboratively fund up to 50% of the Early Childhood Mental Health Program position within the new Office of Early Childhood with a condition that this is a short-term publicprivate partnership to support the position until a longer term state level sustainability strategy is in place. This individual can also serve as a consistent voice who can be at the table to represent the interests and maintain the visibility of the early childhood mental health community across departments/task forces/systems. Host working sessions with private insurance providers and Medicaid to promote relationship-based payment for young children and their caregivers/family and payment for treatment of behavioral challenges that do not meet specific diagnostic criteria. Commit to a funding strategy for early childhood mental health program evaluation that is based on outcomes and intended effects. PROGRAM AVAILABILITY Goal Colorado families and caregivers are able to obtain appropriate and affordable mental health resources and supports for their children and themselves at the promotion, prevention and intervention levels. Objectives A system exists that parents can easily navigate to access the care their young child/family needs. An environmental scan to inform philanthropic impact, public policies and program development 19

21 Every young child and family in need of a mental health provider has access to one who is qualified to provide the specialized services they require and accepts their insurance. Primary care practices adopt an approach that emphasizes a close relationship with parents in addressing the physical, emotional, and cognitive development of young children. Progress There has been more investment by Early Childhood Councils in social-emotional and mental health resources and system development. The Colorado Department of Education Teaching Pyramid initiative has been implemented in an increased number of school districts. Pilots and models of early childhood mental health consultation in child care and primary/pediatric health care continue to be implemented. Capacity to provide more direct services for outpatient and in-home services (e.g. through the Harris Program) has increased. Medical and research fellows are spending more time in early childhood mental health. The recently developed Colorado Early Childhood Social-Emotional and Mental Health Navigation Guide has been launched. Challenges Access to quality programs and services is unequal across Colorado because it is dependent on the geographic area where a family lives as well as the type of insurance coverage they have. Specific programs and initiatives have proven to be effective, but they are not widely available due to capacity and financial limitations (Appendix B identifies the level of evidence for programs in Colorado). The Kempe Therapeutic Preschool closed in August 2011 after nearly 40 years of serving the community by providing day treatment level psychiatric services for preschool children. There is now only one other program in metro Denver providing such services for the many children who have endured significant abuse and trauma and demonstrate high levels of behavioral and psychiatric impairment. Even when early screening is done and problems are identified, providers do not know where to refer families for follow up and treatment. In part, this relates to the lack of a comprehensive statewide database of qualified providers which includes information about their training and qualifications, including their Endorsement status, where they practice, type of payment they accept, etc. Opportunities The Affordable Care Act may provide the opportunity to count young children as covered lives with regard to mental health services and to ensure there is the capacity to serve them. Maternal, Infant, and Early Childhood Home Visiting provided funding to expand home visitation to 15 Colorado counties. Home visitation can provide a comfortable and effective mode of service delivery and possible early identification of mental health difficulties. There have been pilots of early childhood mental health consultation in limited geographic areas of the state. An environmental scan to inform philanthropic impact, public policies and program development 20